Every finding on record at Lorien Taneytown, Inc

During the initial tour of the facility on 09/22/2025, at 9:06 AM, Residents #67 and #17 reported that the facility's food was bland and cold for foods that needed to be warm. An observation of the facility's lunch tray line service was conducted on 9/22/2025 at 12:30 PM. The surveyor requested a test tray at that time. The tray contained Roast beef, steamed vegetables, one dinner roll, margarine, pumpkin pie, vanilla ice cream, cranberry juice, roasted red potatoes, salt, and pepper.Staff #12, the Dietary Director, who was present, took the temperatures of the food items, which showed 137 degrees for the steamed vegetables, 121 degrees for the roasted potatoes, 146 degrees for the Roast beef, 63 degrees for the pumpkin pie, and 61 degrees for the cranberry juice. Staff #12 indicated that the acceptable temperatures should have been 140-165 degrees F for the steamed vegetables, 140-165 degrees F for the roasted potatoes, 40 degrees F or less for the pumpkin pie, and cranberry juice. A review later that day of the facility's policy and procedure on food preparation and service contained a statement that while food is being stored, prepared, served or transported to the residents, it is protected from contamination. It is necessary to keep foods refrigerated below 45 degrees F and heated to temperatures above 140 degrees F to prevent the growth of any pathogenic organisms. However, earlier observations of a test tray, taken directly from the food service line, showed temperatures lower than 140 degrees for foods that required warming and over 45 degrees for foods that needed to be kept cold.In an interview on 9/23/2025, at 4:51 PM, staff #12 reported that she would provide training to her staff on the proper temperatures of the food served to residents.

Based on observations, interviews, and record reviews, it was determined that the facility failed to post the required daily nurse staffing information in a clear and accessible location. This was evident for 31 out of 31 days of staffing records reviewed.The findings include:On 9/22/2025 at 8:40 AM, the Surveyor observed a whiteboard near the central nursing station and asked the Licensed Practical Nurse (LPN)/Unit Manager (Nurse #8) who was responsible for writing the information on the board each day. Nurse #8 stated that the charge nurse was responsible. The Surveyor observed the board and noted the following:The facility name was not included.The manager on duty section was left blank.Two nurses were listed, but their full names and titles (Registered Nurse [RN] or LPN) were not indicated.The Certified Medicine Aide (CMA) and Geriatric Nursing Assistants (GNAs) were listed by first name only.The board included 7-3 but did not specify hours scheduled versus hours worked.Staffing ratios were listed as 9:53, Licensed, 2:53, and Unlicensed 7:53 without clarification of what constituted licensed versus unlicensed staff.When asked if the information was available elsewhere, Nurse #8 stated it was only posted on the whiteboard. She reported that the information was provided to her by the facility Staffing Coordinator (Staff #14). The Surveyor then asked to review the staffing binder. Upon review, there were no previous dates maintained in the binder. When asked where to locate prior postings, Nurse #8 stated that the Staffing Coordinator would have that information.The Surveyor then walked to the second nursing station and observed that no nurse staffing information was posted at that location.On 9/22/25 at approximately 8:45 AM, the Surveyor requested the past month of nursing assignment sheets from Staff #14. They were provided around 10:00 AM. Review revealed that none of the postings from 8/22/25 to 9/21/25 included the facility name, daily census, manager on duty, or total hours scheduled versus worked. Multiple postings also lacked full names and titles of staff (dates: 8/22, 8/25-8/31, 9/1-9/6, 9/8-9/12, 9/14-9/21).On 9/22/2025 at 10:33 AM, the Surveyor conducted an interview with the Staffing Coordinator (Staff #14) and asked her to explain her understanding of the facility requirement for posting nursing staffing information. She stated that she needs to include nurses, aides, and who is on call, and include that the charge nurse on duty will make the room assignments. She stated they also include the date.The Surveyor asked if they typically include the census, and she stated, we don't usually put the census on the daily schedule. The Surveyor asked if they included the hours scheduled versus the hours worked, and she stated, No, that is not included. The Surveyor asked where they post the nursing assignments in the facility, and she stated that they include it in our OnShift (internal computer system). The Surveyor asked if the nursing schedule and assignments are posted for the public, and she stated that they are not. The Surveyor asked if she was aware of the regulatory guidelines for posting the nursing schedule, and she stated, I am not aware.The Surveyor reviewed the concerns over the missing data and asked Staff #14 to look over them. She agreed with the Surveyor's findings and stated that I used to include all the information on the schedule but the staff had complained that it was too much information to include and so I made the change. She said that she didn't realize the regulation was probably the reason the old documentation included all the information and stated that she would go back to posting the schedules daily with the required information.On 9/22/25 at 11:00 AM, the Surveyor spoke with the Director of Nursing (DON), who acknowledged that neither the whiteboard nor paper schedules included all required information and confirmed that staffing assignments are not posted at any nursing station or elsewhere in the facility.

Based on observations and interviews, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents. The findings include:1) An observation of the facility's Refrigerator #10 with Staff #12, the Dietary Director present, on 9/22/2025 at 8:10 AM showed the following:-Leftover onion ring sauce with a date prepared as 9/19/25 and had no use-by date.-Ranch dressing with a date prepared of 9/20/25 and no use-by date.-Leftover orange sesame dressing with a date prepared as 9/21/25 and no use-by date.-Leftover crab syrup with a date prepared as 9/19/25 and no use-by date-An open carton of liquid whole egg with no open date-A container of raw frozen burgers was placed on the top shelf above salad dressings/sauces to thaw. Staff #12 said the burgers were placed in the refrigerator to thaw; however, they should have been placed on the lower shelf. Staff #12 then moved the fresh burgers to the lower shelf.2) An observation of the facility's Walk-in freezer #3 on 9/22/2025 at 8:15 AM showed the following:-An open bag of frozen toasted bread, which had no open or use-by date. Staff #12 said that it should have been put in a Ziplock bag and dated.-Open bags of waffles, pancakes, and chicken tenders were noted with no open or use-by date. Staff stated they should have been ziplocked and dated as well.The continued observation of the freezer temperature was noted to be 10 degrees. Staff said it should be less than 0 degrees.A review of the temperature logs for freezer #3 from July to September 2025 was completed. The form for recording the log indicated that the freezer temperature should be less than zero. However, in July, the recorded temperatures for 28 out of 31 days were above zero degrees, reaching a high of 36. In August, the temperatures recorded for 30 consecutive days ranged from 6 to 28 degrees. In September, the recorded temperatures for 21 days ranged from 3 to 15 degrees. 3) An observation of the facility's walk-in freezer #1on 9/22/2025, at 8:20 AM, showed a bag of meatballs with an open date of 1/16/25 and had no use-by date. Staff #12 stated that it should have been labelled with a use-by date as well. 4) An observation of the facility's Refrigerator #6 on 9/22/2025 at 8:25 AM showed that it contained juices, milk, and sandwiches for Residents. Continued observation of Refrigerator #6's temperature showed a reading of 50 degrees. Staff #12 confirmed that the temperature was 50 degrees and then stated that the refrigerator's temperature should be 40 degrees or lower. A review of the facility's policy on Food Storage stated that every refrigerator must be equipped with an inside thermometer and will not exceed 40 F. Freezer Temperature 0 to -10 F. However, earlier observations and a review of the temperature logs for freezer #3, from July to September 21, 2025, revealed temperatures greater than zero, reaching up to 36 degrees, and the facility failed to respond to these temperatures.In an interview on 9/22/2025, at 2:48 PM, staff #12 stated that she would notify the facility's maintenance department to check the freezer after the surveyor's intervention.During a subsequent interview on 9/23/2025, at 8:11 AM, staff #12 reported that Refrigerator #6 had been completely emptied, and a refrigerator company had been contacted to repair it after the surveyor's intervention. Staff #12 also indicated that Freezer #3 had been repaired following the surveyor's intervention.On 9/25/2025 at 1:26 PM, the chief clinical officer (COO) was made aware of the concerns of not labeling foods, and warmer freezer and refrigerator temperatures. The COO reported that he had already been made aware of all the concerns in the facility's kitchen and had provided training to Staff #12, who would also train all her staff regarding the concerns.

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure the dishwasher was maintained in a safe operating condition, as evidenced by low temperature logs. This deficient practice has the potential to affect all residents who receive meals from the facility's kitchen. The findings include:During a tour of the kitchen on 9/22/2025 at 8:02 AM, staff #12, the Dietary Director, reported to the surveyor that the dishwasher had just broken, so staff had to wash the dishes manually. Later that day, a review of the dishwasher temperature logs from June to August 2025 was done. The form for recording the logs contained the acceptable minimum temperatures for the dishwashing process: wash 140-160 degrees, Rinse 180 degrees or higher. The review also showed that, for the month of June, the recorded final rinse temperatures after breakfast and Lunch were within the range of 100 to 130 degrees for 23 out of 30 days, which were below the minimum final rinse temperatures; and 7 days had no recorded temperatures. July's recorded final rinse temperature logs for 30 out of 31 days were between 130 and 150 degrees, which were below the minimum final rinse temperature of 180 degrees. August's recorded final rinse temperatures after breakfast and Lunch for 28 out of 31 days were within the range of 120 to 135 degrees and below the minimum final rinse temperature of 180.Further review of the manufacturer's information about the dishwasher presented to the surveyor by staff #12 noted that the dishwasher was a high temp dishwasher, which sanitizes dishes using hot water, rather than chemicals. The machine sanitizes at a temperature of 180 F or higher during the final rinse cycle. In an interview, staff #12 confirmed that the final rinse temperature logs recorded after breakfast and Lunch from June to August 2025 were outside the acceptable final rinse minimum of 180 F or higher. Staff #12 added that she was not aware that the temperatures had been out of range for the dishwasher's final rinse. During a subsequent interview on 9/23/2025, at 1:36 PM, staff #12 stated that she did not typically check the temperature logs of the dishwasher, so she was not aware that the temperatures were lower than the acceptable minimum temperature at the final rinse necessary for sanitizing the residents' dishes, flatware, and utensils from June to August. Staff #12 added that she only shut down the dishwasher in the first or second week of September 2025.Staff #12 also indicated that the water heater booster was not working correctly, which was the reason why the final rinse temperature logs were outside the acceptable temperature range. However, the facility did not act upon the low temperature recordings from June to August. In an interview on 9/23/2025 at 4:51 PM, staff #12 stated that she was providing training to her staff on the dishwashing process and what to do when the temperatures were not reading correctly. Staff also indicated that the facility was waiting for a dishwasher company to repair it.

Based on a review of medical records and interviews, it was determined that facility staff failed to immediately report an allegation of resident abuse. This was evident for 1 ( Resident #69) of 4 residents reviewed for abuse during a survey. Findings include:On 9/23/25 at 3:10 PM, a family member reported concerns about the care Resident #69 was receiving. These concerns included an allegation that a nurse threatened to withhold medication from the resident.On 9/24/25 at 4:02 PM, Resident #69, a resident admitted for rehabilitation and without cognitive decline was interviewed. During the interview, Resident #69 stated that on the first day at the facility, a call bell was activated to request eye drops. Resident #69 reported the nurse responded, You aren't getting nothing tonight. Resident #69 confirmed receiving other medications but not eye drops.Additionally, Resident #69 recalled a separate incident in which a nurse was asked to identify the medications in a medication cup. The nurse reportedly replied, I don't know if they are just your medications, and added, If you don't want them, throw them out.On 9/23/25 at 4:19 PM, Nursing Supervisor (Staff #4) was interviewed. Staff #4 stated awareness that the agency nurse (Staff #5) did not administer the prescribed eye drops on the evening of 9/19/25. According to Staff #4, Resident #69 contacted a family member that evening after not receiving the eye drops. The family member called the facility around 10:22 and asked to speak with the nurse supervisor. The Nurse Supervisor Staff #4 then subsequently administered the eye drop medication at 10:30 PM.During the interview, Staff #4 reported asking Staff #5 why the eye drops were not given. Staff #5 allegedly responded, Resident #69 is in a COVID room, and I only go in when I have to. Staff #4 confirmed that the medication was ordered and available in Resident #69's room. Staff #4 also acknowledged a concerning conversation between the agency nurse and Resident #69. Staff #4 reported that she removed Staff #5 form providing care to Resident #69 for the remainder of the shift. Staff #4 advised the oncoming nurse supervisor not to assign Staff #5 to Resident #69 if Staff #5 was scheduled that weekend.Staff #4 acknowledged that threatening to withholding medication due to the resident's COVID status constituted neglect. However, the incident was not reported to the Director of Nursing (DON) or any other facility management at that time.On 9/23/25 at 4:47 PM, the DON and the facility's Chief Compliance Officer were informed of the concerns expressed by Resident #69 and the family.On 9/23/25 at 4:48 PM, the DON and Chief Compliance Officer were interviewed. The DON stated that allegations of abuse or neglect must be reported immediately to the DON or administrator and submitted to the Office of Healthcare Quality (OHCQ) within 2 hours.On 9/25/25 at 10:00 PM, a review of facility-reported incidents revealed that the above allegation was not reported until 9/23/25 at 6:30 PM.

Based on record reviews and interviews, it was determined that the facility failed to thoroughly investigate allegations of abuse. This was evident for 2 (Residents #17 and #55) of 4 residents reviewed for abuse allegations. In addition, the facility failed to protect a resident during the course of an investigation, which was evident for 1 (Resident #17) of 1 resident reviewed for abuse allegations.The findings include:Resident #17 has a medical history of a stroke, resulting in hemiplegia, a condition that causes paralysis or weakness on one side of the body. The resident has a Brief Interview for Mental Status (BIMS) score of 15, indicating no or very little cognitive impairment, suggesting intact thinking and memory. On 9/23/25 at 2:30 PM, the Surveyor reviewed records related to a facility-reported event (FRI) indicating that Resident #17 reported to the facility on 6/26/25 at 1:30 PM that two Geriatric Nursing Assistants (GNAs) had been rough with them when providing incontinence care. The aides reportedly stated that s/he was the equivalent of two people, referencing their weight. The resident further reported that the head of nursing got in on the deal, stating, Have you tried to lift your weight recently? They described feeling like a piece of meat and said, How dare they stand on two legs with two arms and treat me that way. S/he expressed that they did not want to be in that condition and worried about whether they would walk again. The facility obtained statements from Resident #17 and the two GNAs alleged to have been rough, but the investigation did not show evidence that other staff members or residents (aside from the roommate, who stated they were not aware of the incident) were interviewed. The facility suspended the two GNAs during the investigation, but there was no clarification regarding who the head of nursing was or whether that person was suspended. The facility ultimately found the claim unsubstantiated without conducting a full investigation. On 9/23/25 at 3:14 PM, the Surveyor interviewed the Director of Nursing (DON), who confirmed familiarity with the complaint and identified the head nurse as the Unit Manager (Nurse #8). When asked why Nurse #8 was not suspended along with the other alleged perpetrators, the DON stated it was because in an email she indicated she was joking. The DON acknowledged in retrospect that all three staff members should have been suspended during the investigation. When asked whether there was evidence that other residents or staff were interviewed, the DON stated she did not see any in the file. The Chief Clinical Officer (CCO), who joined the conversation, offered to provide the facility with an investigation template, emphasizing that abuse allegations should include interviews with other residents and staff to determine if others witnessed the event or had similar concerns. The DON indicated she would further investigate to determine if additional interviews were conducted. On 9/24/25 at 8:38 AM, the DON informed the Surveyor that no additional residents or staff were interviewed as part of the investigation and provided the email from Nurse #8 claiming she was joking with the resident about their weight. On 9/24/25 at 9:31 AM, the Surveyor spoke with the DON and CCO and reviewed the investigation findings, including Nurse #8's email confirming the joke about the resident's weight, the lack of suspension for Nurse #8, and the absence of interviews with other staff or residents. After this review, the DON acknowledged that the allegation had not been thoroughly investigated in accordance with regulatory guidelines 2) On 9/24/25 review of facility reported incident 335697 revealed that on 3/29/23 Resident #55 reported having received rough care that morning from GNA #6. Review of the facility's investigation documentation revealed documentation of an interview with Resident #55 and a handwritten statement completed and signed by GNA #6 on 3/29/25. No documentation was found to indicate other interviews were conducted in regard to this allegation. On 9/24/25 at 3:58 PM interview with the Director of Nursing (DON) revealed that the Nursing Home Administrator (NHA) usually conducts the abuse investigations but when the NHA is not here then it goes to her (the DON). When asked to describe what is involved in an investigation, the DON included getting statements from the resident, other residents and staff working at the time and potentially family. The DON confirmed that she would interview more than just the resident and the accused. Surveyor then discussed the concern that, based on review of the documentation provided, the only interviews conducted in relation to Resident #55's allegation, was Resident #55 and the accused GNA. As of time of survey exit on 9/25/25 at 2:15 PM no additional documentation was provided in regard to this concern.

Based on record review and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded. This was evident for 2 (#30 and #70) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification.The findings include:The Minimum Data Set (MDS) is a complete assessment of the Resident that provides the facility with the necessary information to develop a plan of care, deliver appropriate care and services to the Resident, and modify the care plan based on the Resident's status. MDS assessments must be accurate to ensure that each Resident receives the care they need.1) Record review on 9/23/2025 at 1:54 PM of the Beneficiary Notification checklist completed and provided by the facility to the survey team showed that Resident #30's Medicare A services in the facility started on 7/31/25 and ended on 9/18/25. However, Resident #30's Discharge MDS, dated [DATE], recorded that Resident #30's Medicare A services ended on 9/19/25.In an interview on 9/23/2025 at 3:49 PM, staff #10, the MDS Coordinator, confirmed that Resident #30's Medicare End date was recorded inaccurately on his/her Discharge MDS dated [DATE].2) A review of Resident #70's medical record contained an MDS assessment dated [DATE] that documented that the Resident's Medicare A services started on 2/14/25 and ended on 4/1/25.However, a continued review of Resident #70's Notice of Medicare Non-Coverage (NOMNC) indicated that Resident's Medicare A services ended on 3/31/25.During an interview on 9/23/2025, at 3:55 PM, staff #10 stated that Resident #70's Medicare End date was 3/31/25 and that his/her MDS assessment, dated 4/1/25, was recorded in error. Staff #10 added that she would correct the MDS assessment to reflect the accurate date.

Based on record reviews and interviews, it was determined that the facility failed to develop a comprehensive care plan within 7 days after the completion of the comprehensive assessment. This was evident for 1 (Resident #26) of 2 residents reviewed for care planning.The findings include:Resident #26 was admitted into the facility in mid-2025.Minimum Data Set- The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions.On 9/24/25 at 11:32 AM, Resident #26's medical record was reviewed and revealed the most recent MDS assessment was conducted for a significant (sig) change with an assessment reference date of 7/22/25. However, there was no documentation to indicate that a care plan meeting took place after the completion of this assessment.The Social Services Director (Staff #9) was interviewed on 9/24/25 at 11:37 AM. During the interview, she reported her role and that she attends the care plan meetings. She indicated that she always documents in the residents' progress notes on what was discussed during the meetings, and a sign-in sheet is provided to the attendees and kept in the resident's hard chart. She also reported that all care plan meetings are scheduled by the MDS coordinator (Staff #10).A subsequent review of Resident #26's medical record was conducted on 9/24/25 at 11:48 AM. The review revealed a progress note by Staff #9 that indicated a care plan meeting took place on 6/17/25 for his/her admission. The review also revealed the sign-in sheet in the resident's hard chart dated 6/17/25. There were no documents to indicate that another care plan meeting was held after 6/17/25.In an interview with the Staff #10 on 9/24/25 at 2:36 PM, she confirmed that she was responsible for scheduling care plan meetings. A review of Resident #26's medical record was conducted with Staff #10, and she reported that the sig change assessment was done due to the resident going in hospice care.Staff #10 also reported that a care plan meeting was required after completing a sig change assessment and when asked if she scheduled one after Resident #26's sig change assessment, she indicated no and stated, I thought for sure we did a care plan meeting for him/her because s/he switched to hospice, but it looks like it was missed.The concern that an interdisciplinary care plan meeting was not conducted after the completion of a comprehensive assessment was discussed with the Director of Nursing (DON) on 9/25/25 at 12:05 PM. the DON verbalized understanding and acknowledged the concern.

Based on record reviews and interviews, it was determined that the facility failed to maintain resident records that were complete and accurate. This was evident for 1) one (Resident #4) of five residents review for unnecessary medications, and 2) one (Resident #69) out of five residents reviewed for abuse.The findings include:1). Resident #4 was admitted into the facility in late 2023 with diagnosis that include hypertension. Hypertension, or high blood pressure, is a condition where the force of blood against your blood vessel walls is consistently too high. This constant high pressure makes your heart work harder and can lead to serious health problems like heart attack, stroke, and kidney disease. Doctors measure your blood pressure (BP) as two numbers, written as a fraction, such as 120/80. Systolic (top number) and diastolic (bottom number) On 9/24/25 at 12:13 PM, Resident #4's medication orders were reviewed. The review revealed an order for Hydralazine for hypertension with instructions to hold if the Systolic Blood Pressure (SBP) was below 100. Resident #4's electronic Medication Administration Record (eMAR) was reviewed on 9/24/25 at 12:25 PM. The area to document the administration of hydralazine had areas indicated for the nurse initials and blood pressure readings. The Licensed practical Nurse (LPN #7) documented on 9/5/25 and 9/6/25 that she held the medication. However, there was no documentation for the BP reading. An interview with the nurse unit manager (LPN #8) was conducted on 9/25/25 at 9:40 AM. During the interview, she reported her expectations from nursing staff when documenting administration of medications with parameters. She indicated that if a medication is held due to parameters like BP, then she expects the nursing staff to document the BP reading and report it to the physician. Resident #4's eMAR was reviewed with LPN #8 and she confirmed that LPN #7 held the Hydralazine on the dates stated above but failed to document the BP reading. LPN #8 also indicated that she could not find documentation to indicate that LPN #7 reported it to the physician. The concern was discussed with LPN #8 that LPN #7 failed to maintain a complete resident record. She Verbalized understanding and acknowledged the concern. LPN #8 stated, she (LPN #7) will be in later this evening, and we will be talking to her about the concern. 2). On 9/23/25 at 4:19 PM, the Nursing Staff Supervisor (Staff #4) reported that Resident #69 called a family member on 9/19/25 around 10:22 PM after not receiving eye medications. The family member then contacted the facility and spoke with Nurse Supervisor #4. Nurse Supervisor #4 confirmed with agency nurse Staff #5 that the eye drop medication had not been administered. Nurse Supervisor #4 stated that the prescribed eye drop medication was administered at 10:30 PM. On 9/24/25 at 12:58 PM, the Medication Administration Audit Report was requested. On 9/24/25 at 1:30 PM, review of the Medication Administration Audit Report revealed that agency nurse Staff #5 documented the eye drops were administered along with the resident's other medications on 9/19/25 at 9:24 PM. On 9/24/25 at 3:08 PM, the Director of Nursing (DON) was interviewed. The DON stated it was expected that nurses document medication administration at the time it was given. Additionally, if a nurse signed for a medication they did not administer, the nurse who administered it must correct the medical record and document the event in the progress notes. On 9/25/25 at 10:26 AM, during an interview, the Director of Nursing reported that re-education for the nursing staff had already been initiated regarding proper medication administration documentation and how to correct a medical record documentation error in the electronic health record.

Based on record reviews and interviews, it was determined that the facility failed to properly obtain a resident's signature on an arbitration agreement. This was evident for 1 (Resident #17) of 3 residents reviewed for arbitration agreements.The findings include:An arbitration agreement is a legal document used in long-term care facilities. It requires that disputes or injuries be resolved through private arbitration instead of through the court system. By signing, a resident waives the right to have a judge or jury decide the case. The arbitrator's decision is usually final and cannot be appealed.On 9/22/25 at 3:05 PM, the Surveyor reviewed Resident #17's arbitration agreement dated 4/25/2025. The document was signed by the resident's spouse and states, in part, that any legal dispute, controversy, or claim.shall be resolved exclusively by binding arbitration.and not by a lawsuit or resort to court processes. It further states, The parties understand and agree that by entering this arbitration agreement they are giving up and waiving their constitutional right to have any claim decided in a court of law before a judge and a jury.An advance directive is a legal document or set of instructions that expresses an individual's wishes for future medical care and treatment in case they become unable to make those decisions themselves due to serious illness or injury.A health care power of attorney is a legal document in which an individual (the principal) designates a trusted person (the agent or health care proxy) to make medical decisions on their behalf when they are unable to do so due to illness, injury, or cognitive decline.On 9/23/25 at 9:19 AM, the Surveyor reviewed Resident #17's medical records which included:An advance directive dated 3/31/2025 naming the resident's spouse as primary agent if you cannot or do not want to make your own healthcare decisions.A medical power of attorney dated 3/31/2025 designating the spouse as healthcare agent if I am unable to make my own health care decisions.A Brief Interview for Mental Status (BIMS) score of 15 indicates no or very little cognitive impairment, suggesting that the individual has intact thinking and memory and can likely function normally within their environment.On 9/23/25 at 10:07 AM, the Surveyor reviewed an assessment dated [DATE], which revealed that Resident #17 had a BIMS score of 15. The Surveyor also reviewed a physician certification dated 4/25/25, which documented that the resident was able to:Understand and sign admission documents,Understand the nature and consequences of treatment,Make rational evaluations of treatment options, andEffectively communicate decisions.On 9/23/25 at 11:09 AM, the Surveyor interviewed the Admissions Coordinator (Staff #15). She stated that arbitration agreements are sent out with admission packets and are typically signed by family members through DocuSign (an electronic signature program) prior to admission. She acknowledged that she does not request documentation to confirm legal authority, explaining that they are family. She further stated she was never instructed to confirm that the person signing had the legal right to complete the arbitration agreement.The Surveyor asked Staff #15 to review Resident #17's chart for documentation showing that the resident had lost capacity or had authorized the spouse to sign legal documents. She located the advance directive and POA documents and acknowledged that they only grant authority if the resident is unable to make their own decisions. She stated, I don't see anything in their documents that show that they are unable to make decisions.On 9/23/25 at 11:44 AM, the Surveyor spoke with the Director of Nursing (DON) and the Chief Clinical Officer (CCO). The DON confirmed that Resident #17 had capacity and agreed the findings were concerning. The CCO later stated that the current process was not a legal way to obtain arbitration signatures and acknowledged that residents with capacity have the right to sign their own documents. He stated the facility would retrain Staff #15 following the survey.On 9/24/25 at 10:30 AM, the Surveyor reviewed Resident #17's care plan and found no evidence that the resident had requested the spouse to sign legal documents on their behalf.On 9/24/25 at 12:27 PM, the CCO provided the Surveyor with a copy of Resident #17's personal financial power of attorney, which had been obtained from the spouse that day. The Surveyor explained that this did not negate the lack of appropriate documentation at the time of admission.On 9/24/25 at 12:31 PM, the Surveyor interviewed Resident #17, who stated they did not remember being asked about an arbitration agreement and did not know what it meant.On 9/25/25 at 8:47 AM, the Surveyor interviewed the DON and the CCO. The CCO acknowledged that the financial POA did not give the spouse the right to sign the arbitration agreement and that the facility's current process must be reviewed and revised. He described the presentation of the financial POA as a [NAME] attempt to remove the citation and agreed that residents with capacity must be asked to sign their own arbitration agreements. He stated that the facility will provide education to Staff #15.

Based on observation, interview, and record review it was determined that the facility failed to follow proper infection control procedures. This was evident for 2 (Resident #25 and #67) of 12 residents reviewed for infection control during the recertification survey.The findings include: 1). Transmission-based precautions (TBP) are a set of practices, designed to reduce the risk of infection by breaking the chain of infection through specific modes of transmission, namely contact, droplet, or airborne transmission. These precautions involve specific measures such as proper patient placement, use of personal protective equipment (PPE), and dedicated patient care equipment to prevent the spread of known or suspected infections. Contact precautions are used for infections that spread by direct or indirect contact with the patient or their environment. This involves wearing gloves and gowns for all patient interactions, single-room placement, and using dedicated or disposable patient equipment. Droplet precautions are used for infections that spread via respiratory droplets produced during coughing, sneezing, or talking. This includes wearing a surgical mask for close contact and patient placement in a single room. A review of physician orders for Resident #25 revealed an order, dated 9/20/25, for Contact/Droplet precautions (isolation) due to COVID infection. On 9/22/25 the facility provided a list of residents who required TBP. Resident #25's name was included on the list. Resident #25 resided in room [ROOM NUMBER]. On 9/22/2025 at 2:04 PM an observation of the closed door of room [ROOM NUMBER] was conducted in order to determine if and what type of personal protective equipment (PPE) was needed to enter the room. A cart with a supply of PPE was next to the door, but there was no sign on the door to indicate that the room had Contact/Droplet precautions, or that any PPE needed to be worn to enter the room. On 9/22/25 at 2:06 PM, the Director of Nursing (DON) was interviewed at the nurses' station for room [ROOM NUMBER]. When asked if either resident in room [ROOM NUMBER] required isolation, the DON turned and asked the Infection Preventionist Nurse (Staff #12) who said yes, one of the residents (Resident #25) had an active COVID infection. When the DON was informed room [ROOM NUMBER] lacked any signage to indicate that it was an isolation room and that PPE was required to be worn to enter it, the DON said there should have been a sign. Staff #12 was then observed to make a sign to place on room [ROOM NUMBER]'s door. On 9/22/2025 at 3:12 PM an interview was conducted with the Chief Clinical Officer (Staff #13) to review the concern that room [ROOM NUMBER] lacked an isolation sign although isolation was ordered. He acknowledged the deficiency. 2.) Resident #67 was a newly admitted resident of the facility with a diagnosis of appendicitis with perforation. An interview with Resident #67 was conducted on 9/22/25 at 8:58 AM. During the interview, s/he reported being on an antibiotic for a wound on the abdomen. It was observed during this interview that the resident was not on Enhanced Barrier Precaution (EBP). There was no sign in or outside the resident's room to indicate such. A brief interview was conducted with the Infection Preventionist (IP) nurse (Staff #12) on 9/22/25 at 2:35 PM. She reported that she reviews resident records to determine if residents need to be on EBP. A list of all residents of the facility who were currently on EBP was requested and provided by Staff #12. Resident #67 was not included in the list. A subsequent interview with Staff #12 was conducted on 9/23/25 at 12:15 PM. During the interview, Staff #12 explained EBP and that there were a lot of misconceptions about it, noting surgical wounds are not part of EBP unless they are infected. Staff #12 was requested to provide the facility's policy on EBP. On 9/23/25 at 1:11 PM, a review of Resident #67's medical record was conducted. The review revealed a medical diagnosis of Infection following a procedure, superficial incisional surgical site dated 9/12/25, and a medical order of antibiotics to be given daily for 7 days indicated for abdominal incision infection with a start date of 9/13/25. On 9/23/25 at 1:14 PM, Staff #12 provided the surveyor with a copy of the facility's EBP policy. A review of the policy with Staff #12 revealed that EBP is indicated to residents with wounds even if the resident is not known to be infected, noting that wounds generally include chronic wounds including but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcer. A review of Resident #67's medical record was conducted with Staff #12 on 9/23/25 at 1:19 PM. During the review, she confirmed that the resident was not put on EBP and was currently taking antibiotics indicated for an infection on a surgical incision site. Staff #12 indicated that based on the medical records reviewed, the resident should have been on EBP and stated, I should have seen that. The concern that appropriate infection control practices were not used on a resident with infection, as evidenced by Staff #12 failing to recognize and institute interventions including the use of EBP to a resident with an infected surgical wound, was discussed with the Director of Nursing (DON) on 9/25/25 at 12:03 PM. The DON verbalized understanding and acknowledged the concern.

Based on observation, record review, and interview, it was determined that facility staff failed to provide treatment and care in accordance with professional standards of practice after a resident fall that resulted in serious injury, resulting in death. Resident #2 died from the injuries sustained from the fall. This was evident for 1 (#2) of 3 residents reviewed for falls with serious injury.As a result of these findings, a state of immediate jeopardy (IJ) was declared on [DATE] at 3:55 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy on [DATE] at 5:30 PM and it was not accepted. The facility submitted a second draft at 5:55 PM, and it was not accepted. The third draft was submitted at 6:09 PM and the facility ' s written plan to remove the immediacy was accepted on [DATE] at 6:20 PM with an alleged date of compliance of [DATE].The findings include:On [DATE] at 3:22 PM a medical record review for Resident #2 revealed the attending physician ' s history and physical note dated [DATE]. Resident #2 was hospitalized for infections and after treatment the resident was sent to the facility for rehabilitation services because s/he was weak. The resident was diagnosed with advanced dementia and anxiety especially at night.On [DATE] at 6:43 AM, a review of the video recording from the facility ' s surveillance camera located at the [NAME] wing nurses ' station was conducted. The video recorded that on [DATE] at 12:08 AM, Resident #2 was sitting in a reclined geriatric chair (referred to as a geri chair, it is a padded chair that reclines and is on wheels) in the nurses ' station unsupervised. The resident stood up and attempted to walk out of the nurses ' station without assistance. The resident was observed falling on their right side, making no attempts to catch themselves. The resident laid motionless on the floor then at 12:10 AM, Geriatric Nursing Assistant (GNA) #6 was observed back at the nurses ' station, without taking a moment to check the resident, she started waving her arms towards the central nurses ' station as if she was trying to get someone ' s attention. Then she walked down to the central nurses ' station. GNA #6 then returned to the resident, who was still lying on the floor and started pulling on the resident ' s left arm as if to roll the resident over before a nurse was able to assess the resident. It was observed the resident had a pool of blood on the floor next to his/her head. The GNAs were placing pads under the resident ' s head.Registered Nurse (RN) #7 and RN #8 were observed walking down the hallway from the central nurses ' station. There was no sound available, but RN #7 was observed leaning over the resident ' s face and head. The nurse was not observed conducting a thorough assessment such as checking for signs of an injury to ensure it was safe to move the resident and conducting a neurological exam (referred to as a neuro check, blood pressure, pulse, respirations, temperature, and level of oxygen in the blood, hand grips, foot pushes, pupil size and reaction.). Neuro checks should have been obtained at the time of the fall and every 15 minutes for the first hour or until Emergency Medical Services (EMS) personnel arrived. She indicated to the GNAs and RN #8 to help her get the resident back into the chair. Once the resident was back in the chair, RN #7 leaned over the resident for a few minutes and moved the resident ' s hands. When the resident was placed back in the chair, resident #2 was observed to have a round knot on the right temple and his/her nose was bloody. Without conducting a thorough assessment, a neuro check, and/or rendering first aid to the resident, At 12:15 AM RN #7 and RN #8 left the resident with the GNAs and walked back towards the central nurses ' station. It was observed on the video that the knot on the resident ' s temple grew into an oval shape, however the nurses left so they were unaware that this was happening. RN #8 came back at 12:25 AM and wrote down a few things then left at 12:27 AM. She failed to assess the resident for changes or conduct a neuro check. EMS arrived at 12:46 AM, 35 minutes after staff were aware the resident had fallen. RN #7 came back at 12:51 AM, after EMS arrived.A review of the EMS Comprehensive Report on [DATE] at 3:45 PM, revealed 911 was called on [DATE] at 12:41 AM, 31 minutes after the resident fell. EMS was dispatched at 12:43 AM. Per the report the residents ' blood oxygen level decreased and the resident needed supplemental oxygen. EMS staff were unable to get the oxygen back to a normal level before arriving at the nearest hospital. The resident was deemed a level 3 priority resident. On [DATE] at 8:24 AM the emergency room report read that Resident #2 had a computerized tomography (CT) scan of the head which showed s/he suffered from hemorrhaging on the left side of the brain to include bleeding at the site of the hematoma on the resident ' s head that could be viewed in the video. The injury warranted surgical intervention; however, the family chose not to put the resident through the surgical procedure. The resident was given medications to reverse the bleeding, however, subsequently died [DATE] at 9:16 AM. The physician documented the cause of death was due to an accident at the nursing home.A telephone interview with the resident ' s family member and their spouse on [DATE] at 11:55 AM revealed they watched the video recording of the surveillance camera. They stated they were appalled by the lack of concern and care provided by the facility staff at the time their family member fell. An interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 10:57 AM revealed that they had a Nurse ' s How to Book at the central nurses ' station. There was a procedure for sending residents to the hospital via 911. Review of the procedure with LPN #2 revealed the following: Step 1 stated to obtain an order from the doctor to send the resident out 911 unless a real emergency, Step 2 prepare the paperwork for transfer, Step 3 was to call 911. When LPN #2 was asked if a resident had an unwitnessed fall and had a large hematoma on their temple would a nurse wait until Step 3 to call 911, she reported she would call 911 first. Furthermore, she stated in that case (a head injury) this procedure goes out the window. She reported she would stay with the resident or ask another nurse to stay with them. When asked if the fall occurred at the [NAME] wing nurses ' station, she reported she could stay with the resident and get all the paperwork ready at that nurses ' station.On [DATE] at 11:05 AM a telephone interview with RN #7 revealed she failed to stay with the resident, conduct neuro checks, and render first aid because she wanted to send the resident to the hospital as soon as possible after she saw the injuries. However, she failed to call 911 for 31 minutes after the resident fell. The nurses ' station where the resident fell had a phone, computer, and printer. In addition, she had RN #8 and RN #10 on duty but failed to ask for assistance to ensure the resident was transferred for emergency care safely and quickly. An interview with RN #8, who was being oriented to the facility by RN #7 when the accident occurred, revealed that she was concerned by the lack of monitoring and response to the resident's needs, however she failed to take action. A telephone interview with the Director of Nursing (DON) on [DATE] at 8:41 AM revealed she had concerns about RN #7 ' s lack of immediacy during the incident. She stated that the assessment could have been better. When asked what action she took to address her concerns she stated that she had a conversation with RN #7. However, there was no documented evidence of training, or counseling regarding the concerns.During an interview with the Medical Director on [DATE] at 11:10 AM, he reported he had not watched the surveillance video footage of the fall. The content was reviewed with him. He stated that based on the content reviewed, there were errors made. He reported that if a resident had a head injury, he would expect the nurse to call 911 immediately before calling him. He stated that the nurse should have obtained a set of vital signs immediately to ensure no cardiac issues caused the fall. Then the nurse should have conducted the neuro checks to determine if the resident had any deficits. He stated that when a resident has a rapidly growing hematoma on their head, pressure should be applied to stop possible bleeding. Especially when the resident was on an anticoagulant and showing signs of active bleeding from the fall.The provisions of the plan to remove the immediacy included the following:1.a. RN #7 and RN #8 are suspended immediately for not following facility policy and procedure; not performing a thorough assessment including a neuro check and vital signs; and moving the resident prior to performing a proper assessment.b. The results of the investigation will determine progressive disciplinary action up to and including termination and if warranted a report to the Board of Nursing.c. If RN #7 and RN #8 return to work they will be educated before they work the shift.d. The investigation will be concluded by [DATE].2.a. Licensed Nurses (facility, contract, and agency) will be in-serviced on the following policies and procedures: Assessment of the Resident Post Fall Notification of 911 in Emergency Situations Without Notifying the Physician First Observation of Neurological Signs Bleeding.b. In-services will be provided by the DON and Infection Preventionist.c. New agency staff will receive a packet containing these policies and procedures when they arrive at the facility at the front desk and/or given by the charge nurse on the unit.d. The agency nurse will sign a receipt roster that they have received the information.3. The facility will be in compliance by [DATE].On [DATE] at 8:15 AM, an onsite visit was conducted. After validation of the implementation of the facility ' s plan of removal, which included staff interviews and record reviews, it was determined the facility met the minimum standards of compliance to remove the findings of an Immediate Jeopardy on [DATE] at 9:50 AM.Cross Reference: F689 and F726

Based on observation, record review and interview, it was determined that facility staff failed to ensure that residents had adequate supervision to prevent falls with serious injury. As a result of this deficient practice Resident #2 died due to the injuries sustained from a fall. This was evident for 1 (#2) of 3 residents reviewed for falls. As a result of these findings, a state of immediate jeopardy (IJ) was declared on 6/20/25 at 4:55 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy on 6/20/25 at 6:40 PM and it was not accepted. The facility submitted a second draft at 7:52 PM, and it was not accepted. The third draft was submitted at 8:02 PM and the facility ' s written plan to remove the immediacy was accepted on 6/20/25 at 8:30 PM with an alleged date of compliance of 6/23/25.The findings include:A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 6/18/25 at 3:22 PM a medical record review for Resident #2 revealed the attending physician ' s history and physical note dated 4/8/25. Resident #2 was hospitalized for infections and after treatment the resident was sent to the facility for rehabilitation services because s/he was weak. The resident was diagnosed with advanced dementia and anxiety especially at night. Review of the progress notes revealed the resident frequently tried to get out of bed without assistance. A review of the baseline care plan revealed that staff noted the resident had a risk for falls, however, failed to implement resident-centered interventions to address the level of supervision the resident required to prevent accidents. Facility staff checked that the resident needed floor mats.On 6/20/25 at 6:43 AM a review of the video recording from the facility ' s surveillance camera at the [NAME] wing nurses ' station was conducted. The video was time stamped for 4/19/25 at 11:36 PM, and showed Resident #2 was brought to the nurses ' station by GNA #5 and GNA #6. The resident was in a reclined geri-chair, covered with a blanket and sheet. At 11:45 PM GNA #5 left the nurses station and then at 11:56 PM GNA #6 left the nurses ' station and Resident #2 was left unsupervised. At 12:06 AM on 4/20/25, Resident #2 was observed throwing the covers back and attempting to stand up. The resident attempted to push the reclined footrest down, but could not. The gerichair started moving back as the resident continued to try to stand. Then GNA #5 returned to the nurses ' station and attempted to get the resident to scoot back in the chair but was unsuccessful. When GNA #6 returned a few seconds later, they both repositioned the resident in the reclined gerichair. The GNAs failed to offer the resident to walk, go to the bathroom, food or a drink to determine the possible reason the resident was trying to get up. GNA #6 wrapped the resident ' s feet with the blankets as they both left the nurses ' station at 12:08 AM. After attempting to get out of the reclined geri chair without assistance the GNAs left the resident unsupervised a second time. After the GNAs left, The resident got out of the chair, threw the covers up, and after unwrapping his feet from the blanket, stood up. The resident used furniture in the nurses ' station to hold on to, made their way to the counter height portion of the desk and fell. The resident fell on the right side and made no attempts to catch themselves. The resident laid motionless on the floor and at 12:10 AM, GNA #6 was observed back at the nurses ' station, and she started waving her arms. Then without checking to see if the resident was ok, she walked down to the central nurses ' station. GNA #6 returned to the resident, who was still lying on the floor and started pulling on the resident ' s left arm as if to roll the resident over before a nurse was able to assess the resident. It was observed the resident had a pool of blood on the floor next to his/her head. The GNAs were placing pads under the resident ' s head.RN #7 and RN #8 were observed walking down the hallway from the central nurses ' station area. Upon arrival, there was no sound available, but RN #7 was observed to lean over the resident near his/her head and shoulders for a few seconds. The nurse was not observed conducting a thorough assessment such as checking for signs of an injury to ensure it was safe to move the resident and conducting a neurological exam (referred to as a neuro check, blood pressure, pulse, respirations, temperature, and level of oxygen in the blood, hand grips, foot pushes, pupil size and reaction.). Staff were observed picking up the resident and sitting the resident back in the reclined geri chair. Once back in the geri chair a large knot was observed on resident #2 ' s right temple and the resident ' s nose was bleeding. RN #7 leaned over the resident for a few seconds and left the nurses ' station without rendering first aid. Further review of the video revealed that RN #7 did not go back to the nurses ' station to check on the resident, until EMS arrived 35 minutes later. The GNAs wiped the resident ' s nose and the resident wiped his/her nose. However, at no time did staff apply pressure to the top of the nose to stop the bleeding. The GNAs changed the blankets because they were soiled with blood. EMS arrived at 12:50 AM and took the resident to the local acute care hospital where the resident subsequently passed away. A review of the EMS Comprehensive Report on 6/20/25 at 3:45 PM, revealed 911 was not called until 4/20/25 at 12:41 AM, 31 minutes after the resident fell. EMS was dispatched at 12:43 AM. Per the report the residents ' blood oxygen level decreased and the resident needed supplemental oxygen. EMS staff were unable to get the oxygen back to a normal level before arriving at the nearest hospital.On 7/2/25 at 8:24 AM the emergency room report read that Resident #2 had a computerized tomography (CT) scan of the head which showed s/he suffered from hemorrhaging on the left side of the brain to include bleeding at the site of the hematoma on the resident ' s head that could be viewed in the video. The injury warranted surgical intervention; however, the family chose not to put the resident through the surgical procedure. The resident was given medications to reverse the bleeding, however, subsequently died 4/20/25 at 9:16 AM. The physician documented the cause of death was due to an accident at the nursing home.Review of the facility ' s investigation file on 6/18/25 at 2:17 PM a review of the facility ' s investigation file revealed an email dated 4/23/25 at 4:24 PM, written by GNA #6 (agency staff) on 4/23/25. The statement read that when she came on duty and during her first rounds, Resident #2 was trying to get up and wander around. She stated that she and GNA #5 transferred the resident to the gerichair and reclined the chair. She wrote that the resident was brought to the nurses station so they could watch the resident. After a while the resident seemed to calm down, so she went to answer a call light, she heard Resident #2 ' s chair alarm so she came out to check on him. She found the resident on the floor and went to the nurse for assistance. GNA #6 was not available for an interview. A review of the statement written by GNA #5 (agency staff) noted that she had heard the resident ' s chair alarm and when she came back to the nurses ' station the resident was on the floor.On 6/18/25 at 5:16 PM during a telephone interview with GNA #5 she reported that on 4/19/25, when she and GNA #6 came on duty they were told that the resident had been trying to get out of bed. She reported that the 3-11 PM supervisor (she did not know the name of the supervisor) told her and GNA #6 that they should get Resident #2 up in a recliner because s/he was a fall risk. She reported that she had not been assigned to the resident that night, but she was working with the GNA who was assigned to the resident in the west hallway. She reported that she assisted GNA #6 to get the resident out of bed and into the recliner geri chair. She reported that she knew that when a resident was up in a geri chair for behaviors they were supposed to have eyes on them at all times. When asked why this was not the case for Resident #2, she stated that they [GNAs] needed to make their rounds and there was no one to watch the resident. During the investigation it was determined that there were 3 nurses sitting at the central nurses ' station at the time of the fall.An interview with GNA #13 revealed that staff would bring a resident who was a fall risk to the nurses ' station at night when they were concerned about the resident ' s safety. She reported, when we get them up we are supposed to keep eyes on them at all times. She reported this was the facility ' s policy. When asked what she does if she needs to tend to another resident, she stated the nurse would watch them. An interview with RN #7 revealed she was sitting in the central nurses ' station and was unaware that the resident was up in the recliner. She stated that she failed to do a thorough assessment because when she observed the resident head injury she wanted to call 911 and get the paperwork ready to go out. She reported was aware there were 2 other nurses on duty that evening RN #8 [orientee] and RN #10. However, review of the EMS report revealed she failed to call 911 until 12:41 AM, 31 minutes after the resident fell. During an interview with the DON she was asked what she expected staff to do when they had a resident who was trying to get out of bed. She stated staff should check to see if the resident needed anything such as toileting, food, and or drink. Then if they continue to try to get up they may place them in a chair at the nurses ' station. However, if they get them out of bed then they need to have eyes on the resident at all times. When asked if she watched the surveillance video for this incident on 4/20/25. She stated she had and her concerns were the lack of urgency when staff responded to the fall. She stated that the assessment was not thorough. She reported that she had an extensive talk with RN #7 regarding the response to the incident. Additionally, she educated staff regarding the need to provide supervision for residents who were a fall risk. An interview with the Nursing Home Administrator (NHA) on 6/20/25 at 8:27 AM revealed she had reviewed the video with the DON while investigating the fall. She was unable to recall when she reviewed it and reported she would look back on her notes and get back to the surveyor. However, she failed to do so by the end of the survey. The provisions of the plan to remove the immediacy included the following:1. In-service on Fall Precautions and 1:1 Supervision Policy and Procedure- will be completed by 06/23/2025 by the Director of Nursing and Unit Manager.2. New Policy and Procedure on Fall Risk Identification and 1:1 Supervision Protocol-see attached will be in-serviced by the Director of Nursing and Unit Manager by 06/23/2025.3. [NAME] dots placed on resident name door plates for high risk of falls on 6/20/2025 with staff education on Fall Alerts/Green Dots completed by 06/23/2025 by Unit Manger and Director of Nursing4. New Policy and Procedure for educating agency nursing staff developed on 06/20/25. Agency staff will receive the in-service at the time they report on duty through the front desk staff and/or charge nurse and it will be made part of the orientation packet for new agency nursing staff. The facility will use the agency roster in Kronos to assure compliance. -See attached policy. Compliance date of 06/23//2025. 5. Overall compliance date of 06/23/2025.On 6/24/25 at 9:30 AM, an onsite visit was conducted. After validation of the implementation of the facility ' s plan of removal, which included staff interviews and record reviews, it was determined the facility met the minimum standards of compliance to remove the findings of an Immediate Jeopardy on 6/24/25 at 3:45 PM.Cross Reference: F684, F726, and F940

Based on record review and interview, it was determined that the facility failed to develop a mandatory training course that included the facility's standards, policies, and procedures regarding their Infection Prevention and Control (IPC) program. This was evident during the review of the facility's training program and has the potential to affect all residents. The findings include: On 6/26/25 at 11:36 AM the printout for the Infection Control training course that was required for facility staff to review on hire and annually thereafter was conducted. The training was an overview of infection control and failed to include the standards, policies and procedures of the facility IPC program. An interview with the Director of Human Resources (DHR) on 6/24/25 at 2:44 PM revealed the facility had an online training program that was sent from the corporate office for the facility staff to complete on hire and annually thereafter. She reported there were no online training requirements for the contracted staff. The findings were reviewed with the Director of Nursing and Nursing Home Administrator on 6/26/25 at 1:43 PM. They were unaware that the required IPC training was supposed to be facility specific. Cross Reference F940

Based on record review and interview, it was determined that the facility failed to ensure that all staff who worked directly with residents had communication training. This was evident for 1 (#5) out of 3 contracted staff. The findings include:A review of Staff #5's employee file on 6/23/25 at 1:48 PM revealed she was contracted through a staffing agency and started working at the facility in 10/2023. The facility failed to ensure that she had communication training as required.An interview with the Director of Human Resources (DHR) on 6/24/25 at 2:44 PM revealed the facility had no online training requirements for the contracted staff. She reported that the agency that employed them provided the required trainings. She reported that she does not review their training program when they start working at the facility. The findings were reviewed with the Director of Nursing and Nursing Home Administrator on 6/26/25 at 1:43 PM.Cross Reference F940

Based on record review and interview, it was determined that the facility failed to develop all the required training requirements and have a process in place to ensure that all staff received the required trainings. This was evident for 3 (#7, #9, and #15) of 4 facility staff reviewed training requirements and 2 (#5, #6) of 3 contracted staff reviewed for training requirements. The findings include:1) A review of Staff #7's employee file on 6/23/25 at 1:55 PM revealed she was hired in 2019. She had not received training on the facility specific Compliance and Ethics training, Quality Assurance Performance (QAPI) and Improvement training, and Infection Control and Prevention (ICP) training. 2) A review of Staff #9's employee file on 6/23/25 at 1:28 PM revealed she was employed by the facility in 2024. She had not received training on the facility specific Compliance and Ethics training, Quality Assurance Performance (QAPI) and Improvement training, and Infection Control and Prevention (ICP) training.3) A review of Staff #15's employee file on 6/23/25 at 1:20 PM revealed she had been employed by the facility since 2021. She had not received training on the facility specific Compliance and Ethics training, Quality Assurance Performance (QAPI) and Improvement training, and Infection Control and Prevention (ICP) training. 4) A review of Staff #5's employee file on 6/23/25 at 1:48 PM revealed she was contracted through a staffing agency and started working at the facility in 10/2023. The facility failed to ensure that she had communication and behavioral Health training. In addition, they failed to ensure that she received training based on the facility's program policies and procedures for compliance and ethics training, QAPI, and ICP. 5) The employee file for Staff #6 was reviewed on 6/23/25 at 1:28 PM and this review revealed she was employed by a staffing agency and started working at the facility in 3/2025. The facility failed to ensure that she had communication training. She had not received the facility specific program policies and procedures training for compliance and ethics, QAPI, and ICP. An interview with the Director of Human Resources (DHR) on 6/24/25 at 2:44 PM revealed the facility had an online training that was sent from the corporate office for the facility staff to complete on hire and annually thereafter. She reported there was no orientation or onboard training requirements for the contracted staff except for some contracted staff were required to shadow another staff member for their first 8-hour shift. Reviewed the finding on 6/25/25 at 12:50 PM with the Nursing Home Administrator. She reported that they had provided the QAPI and ICP training to the facility staff and offered to bring a printout for that training. She was unaware if the training was facility specific as it was sent from the corporate level. On 6/26/25 at 11:36 AM the printout for the QAPI and ICP trainings were reviewed and revealed that they were generic and not facility specific as required. Cross Reference F941, F944, F945, F946, and F949

Based on record review and interview, it was determined that the facility failed to have a process in place to ensure that all staff received facility specific compliance and ethics training. This was evident for 2 (#5, #6) of 3 contracted staff reviewed for training requirements. The findings include:1) A review of Staff #5's employee file on 6/23/25 at 1:48 PM revealed she was contracted through a staffing agency and started working at the facility in 10/2023. The facility failed to ensure that she received the mandatory, facility specific compliance and ethics training. 2) The employee file for Staff #6 was reviewed on 6/23/25 at 1:28 PM and this review revealed she was employed by a staffing agency and started working at the facility in 3/2025. The facility failed to ensure that she received the mandatory, facility specific compliance and ethics training.An interview with the Director of Human Resources (DHR) on 6/24/25 at 2:44 PM revealed the facility had no online training requirements for the contracted staff. She reported that she does not review their training list prior to their first day at the facility. Reviewed the finding on 6/25/25 at 12:50 PM with the Nursing Home Administrator. She acknowledged the concern. Cross Reference F940

Based on observation, record review, and interview it was determined that the facility failed to ensure that they had competent staff on duty to provide care to their residents. This was evident for 1 (#2) of 3 residents reviewed for falls with serious injuries.The findings include:On [DATE] at 6:43 AM a review of the video recording from the facility's surveillance camera at the [NAME] wing nurses' station was conducted. The video was time stamped for [DATE] at 11:36 PM. Resident #2 was observed being pushed in a reclined Geri chair to the nurses' station by GNA #5 (agency staff) and GNA #6 (agency staff). At 11:56 PM GNA #6 left the resident unsupervised in the nurses' station. Then at 12:06 AM on [DATE], Resident #2 was attempting to get out of the chair unassisted and GNA #5 and #6 came back and repositioned the resident in the chair. Both GNAs left the nurses' station and Resident #2 was unsupervised in the reclined Geri chair after the resident was trying to get out of the chair unassisted. Immediately after the GNAs left the nurses' station, the resident was able to get out of the chair and attempted to walk out of the nurses' station unassisted. The resident fell, hitting his/her head. The resident later died at the hospital due to the injuries from the fall. A review of GNA #6's (the GNA who was assigned to care for Resident #2) employee file on [DATE] at 1:38 PM revealed was employed by an agency. The file provided had no evidence that the GNA's level of competence was evaluated to ensure she could safely provide care to the residents. An interview with the Human Resources Director (HRD) on [DATE] at 2:44 PM revealed that when an agency staff member started at the facility they were required to shadow another GNA for their first shift. However, there was new hire checklist to documentno record keeping that this occurred and what was reviewed with them. Secondly, the facility provided no training or evaluations for the agency staff. Agency staff receive a packet of information from the front desk on their first day. On [DATE] at 8:53 AM an interview with the Staff Developer (SD) revealed she had no training or competency program for the agency staff. A telephone interview with the Director of Nursing (DON) on [DATE] at 8:41 AM revealed she watched the video and was concerned that GNA #6 had left the resident unsupervised. During a subsequent interview on [DATE] at 9:46 AM with the DON she confirmed they had no process for training and evaluating the agency staff. She reported that their competencies were completed through the agency, however, there was no evidence of this being done. 2) A continued review of the video on [DATE] at 6:43 AM revealed Resident #2 lying on the floor after the fall and GNA #6 finds the resident and goes up to central nurses' station and comes back. Then RN #7 and RN #8 (who was being precepted by RN #7) were observed walking down the hallway from the central nurses' station area. RN #7 failed to appropriately assess the resident for injuries prior to moving the resident off the floor. RN #7 failed to conduct neurological assessment (referred to as a neuro check, blood pressure, pulse, respirations, temperature, and level of oxygen in the blood, hand grips, foot pushes, pupil size and reaction.). The resident was observed to have a large knot on his/her right temple and a nosebleed. RN #7 left the resident before rendering first aid. Because she left so quickly after the fall she was not aware that the knot on the resident's head was growing rapidly which can be a sign of active bleeding. She failed to check on the resident until emergency medical services) EMS arrived 36 minutes later. A review of the EMS Comprehensive Report on [DATE] at 3:45 PM, revealed 911 was not called until [DATE] at 12:41 AM, 31 minutes after the resident fell.A telephone interview with the Director of Nursing on [DATE] at 8:41 AM revealed she had concerns with RN #7's lack of immediacy during the incident and that she had not fully assessed the resident. Cross Reference: F684 and F689

Based on observation, interview with staff, and medical record review, the facility failed to meet the requirement to provide a system to account for the reconciliation of all controlled medications and ensure that an account of all the controlled drugs was completed with two licensed nurses at the change of each shift. This was evident for 3 of 3 available narcotic count logs. Findings Include: Tour of the unit on 07/14/22 at 1:28 PM to check for compliance of Medication Storage and Labeling revealed the Controlled Drug Count Verification Sheets. Several empty spaces for signatures were observed in the shift to shift verification log noted from March 2022 through the present day July 2022. On 07/14/22 at 2:30 PM, Surveyor requested the schedule for specific days from March to June of 2022 that were noted on the narcotic log where there were missing signatures over multiple shifts to verify if staff worked over multiple shifts in a row. According to the schedules provided to the survey team, no staff worked multiple shifts on the days noted with missing signatures on the log. During completion of medication storage task, 07/15/22 10:45 AM, Surveyor interviewed Nurse Manager LPN# 25 about what processes are in place to comply with the requirement of narcotic verification. The Nurse Manager, LPN # 25 was unable to show the Surveyor the process. However, LPN #25 verbalized that for the Inventory of Control and Controlled Substances; nurses should ensure that the incoming and offgoing nurses count all Schedule II controlled substances and other medications at the change of each shift or at least once daily and document the results on the Controlled Drug Count Verification Log. This concern was reviewed with the Nurse manager and the DON throughout the survey and again during exit.

Based on medical record review and interview with facility staff, it was determined that the facility contracted pharmacist failed to identify recommendations were followed up on. This was evident for 1 of 5 residents reviewed for unnecessary medications. Pharmacy reviews are to occur monthly at a minimum to determine any irregularities in a resident drug regimen and report to the physician. The findings include: Review of the medical record for Resident #20 on 7/12/2022 at 2:04 PM for unnecessary medications, specifically regarding the use of a [CONDITION(S)] medication, trazadone an antidepressant and sleep aide, revealed a recommendation from the pharmacist completed on 2/26/2022 to change the medication from AM to PM secondary to the risk of falls. The consult was signed by the resident's attending physician # 27 and the change was notated as agreed upon. Further review of Resident #20's medication administration records (MAR) for March through June 2022, revealed Trazadone was ordered and administered with the morning medications. The medication was not ordered to be changed to 'bedtime' until 6/13/2022. Resident #20's medical record failed to reveal any other pharmacy recommendations from February to July 2022. The pharmacist failed to identify the failure of the facility to implement the agreed upon recommendation to change the Trazadone from AM to PM from March 2022 to June 2022. This concern was reviewed with the DON throughout the survey and again during exit. Cross reference with F758